Mr B had health problems including kidney disease, high blood pressure and heart failure. He could not go out without help. His family complained that poor GP care and treatment led to Mr B's deterioration and death.
What happened
When Mr B suddenly became short of breath, his family contacted his GP Practice. A GP spoke to the family over the telephone and, believing that Mr B had heart failure, increased his dose of diuretic. Two months later, Mr B was again short of breath and a GP visited him at home. The GP again increased Mr B's diuretic, and referred him to a community heart failure nurse. Mr B was short of breath over a month later and his family went to the Practice for advice. The Practice told them to talk to the heart failure nurse. Mr B's breathing and kidney problems deteriorated over the next few months, and he died.
What we found
The Practice provided some appropriate care for Mr B. However, there were also serious failings. The Practice did not visit Mr B at home and examine him all the times it should have, and did not investigate Mr B's sudden breathlessness, or refer him to a cardiologist when he was first short of breath. Plans to follow up Mr B were inadequate, and a GP did not assess the situation before the Practice told Mr B's family to talk to the heart failure nurse. Also, the Practice did not do all that it
should have to ensure effective communication with Mr B's family. Our investigation concluded that while these failings caused Mr B anxiety, discomfort, and distress, and were also upsetting and distressing for his family, they did not lead to Mr B's death.
Putting it right
We recommended that the Practice write to Mr B's family to acknowledge the failings, and to apologise for the injustice this caused. We also recommended that it develop an action plan to learn lessons from the complaint.
A GP practice
Greater Manchester
Not applicable
Apology
Recommendation to learn lessons or draw up an action plan